An Epic Big Bang Boston Medical Center s Experience

Transcription

1 An Epic Big Bang Boston Medical Center s Experience Geralyn Saunders MSN RN CNIO Cathy McDonough McGrath MS RN Sr Clinical Informaticist Renee Rolfe MSN RN CNL Clinical Informaticist Rachel Greer RN Application Analyst II

2 Boston Medical Center 496-bed, Academic Medical Center - Affiliated with Boston University Medical School The largest safety net hospital in New England Mission: to provide consistently accessible health services to all Full spectrum of pediatric and adult care services, from primary care and family medicine to advanced specialty care. Largest and busiest provider of trauma and emergency services in New England and in 2013 the Emergency Department had approximately 130K visits. 2

3 Project Scope Legacy BMC System Inpatient Clinicals: Sunrise Clinical Manager Inpatient Pharmacy: Centricity Pharmacy Inpatient OB: CPN (documentation only) Outpatient Clinicals: Logician Emergency Department: PICIS (IBEX) Operating Room: PICIS OR Manager Operating Room: PICIS Anesthesia Manager HIM: Softmed Bedboard Medilinks: Respiratory Care Medilinks: Rehab Therapy Epic Replacement EpicCare Inpatient Epic Willow EpicCare Stork EpicCare Ambulatory Epic ASAP Epic OpTime Epic OpTime Epic HIM Epic Bedtime EpicCare Inpatient/Ambulatory EpicCare Inpatient/Ambulatory

4 Project Vision and Scope 4 Previous State Current State CPN Logician BHN Logician CHC* SCM ED PulseCheck GE Pharm SoftMed Patient Keeper Anes Mngr OR Mngr HIE* 4

5 BMC s History of Health IT Implementation Early Adopter of EHR including CPOE Best of Breed: multiple interfaces Highly Customized: making upgrade difficult Struggled with Decision Making and Clinician Involvement Imperfect Governance Structure Poor Track Record with Optimization 5

6 BMC s Key Challenges Fast Track Implementation 18 months from contract signing (Dec 2012) to inpatient go-live (May 2014) Drivers: Meaningful Use, ICD-10, Quality Agenda Broad scope of implementation, particularly for inpatient go-live Needed front-line clinicians to embrace change and challenge the status-quo thinking Needed to empower clinical leaders to steer this initiative to success. Quick decision making required with clear governance & escalation pathways Needed efficient mechanism to gather clinical input to: Narrow design options Define pros and cons for options Make clinician-driven decisions in the context of limited time and resources 6

7 Initial Plan of Attack Established CNIO role Aggressive analyst hiring and initial training in WI Divided inpatient project into workstreams to support concurrent design and build activities in different clinical areas Developed escalation paths for issue resolution Clinical practice issues: MD & RN leadership councils Project/Technical Issues: cascade of leadership forums from integrated project managers meeting to organizational steering committee Developed Clinical Lead Program to co-lead each workstream with IT Build team lead Secured funding Aggressive internal recruitment 7

8 Highlights of the Clinical Lead Role MD-RN dyad co-leading with ITS build team lead Joint responsibility and accountability for scope, timeline and quality of deliverables Clinical leads empowered to make build and design decisions under the project guiding principles Clinical leads brought their local workflow expertise and integrated them into the decision making process Escalated challenging clinical/workflow decisions to weekly clinical lead meetings Defined adoption, training, and communication strategy for each key module 8

9 BMC emerge Clinical Leads Program Clinical Leadership Dr. Eric Poon, MD MPH, CMIO Geralyn Saunders, RN MSN, CNIO Inpatient Leads Outpatient Leads ED Leads OB Leads Peri-Op Leads Heme-Onc Leads Pharmacy Leads Marie McDonnell, MD Jim Meisel, MD Mike Ieong, MD Chris Manasseh, MD Cathy McGrath, RN Janet Eagan, RN Laura McLean, RN Meg Grande, RN Devin Mann, MD Sep Sekhavat, MD Lori Stevens, RN Andy Ulrich, MD Renee Rolfe, RN Ron Iverson, MD Laura Calcagni, RN Jeffrey Kalish, MD Mauricio Gonzalez, MD Nancy Giacomozzi, RN Ginny Craig, RN Michelle Redmond, RN Ken Zaner, MD Laura MacLean, RN Je Lee, RPh Je Lee, RPh Meg Grande, RN Renee Rolfe, RN Charlie O Donnell, RT 9

10 emerge Clinical Lead Team Eric Poon, MD MPH - CMIO Inpatient Leads Marie McDonnell, MD (Endocrine) Jim Meisel, MD (Hospitalist) Mike Ieong, MD (MICU) Chris Manasseh, MD (Fam Med) ED Lead Andy Ulrich, MD OB Lead Ron Iverson, MD PeriOp Lead Jeffrey Kalish, MD (Vascular Surgery) Heme-Onc Lead Ken Zaner MD Quality Lead James Moses MD Outpatient Leads Devin Mann, MD (GIM) Sep Sekhavat (Pediatric Cardiology) Practice Mgt Lori Stevens, RN Geralyn Saunders, RN MSN, CNIO Nursing Cathy McGrath, RN (Med/Surg) Meg Grande, RN (Med/Surg) Janet Eagan, RN (ICU) Robert Elloyan, RN (ICU & Devices) Laura Calcagni, RN (OB) Nancy Giacomozzi, RN (OR) Virginia Craig, RN (OR) Michelle Redmond, RN (OR) Renee Rolfe, RN (ED) Laura Maclean, RN (Oncology & Pedi) Pharmacy Je Le, RPh Ancillary Charlie O Donnell, RT Plus department-based subject matter experts to support Clinical Content Build Out and Ad hoc workgroups 10

11 Implementation Overview Inpatient Timeline Project Definition & Direction Setting Discovery & Project Scope Validation System Build & End- User Adoption Testing, Training, & Go-Live Post-Live Support & Optimization Rollouts & Upgrades Education, Analysis & Design Implementation Adoption & Transformation GO-LIVE PHASE 0 PHASE 1 PHASE 2 PHASE 3 PHASE 4 PHASE 5 PHASE 6 Oct 12-Feb 13 Feb 13-Apr 13 Apr 13-May 13 May 13-Nov 13 Dec 13-May 14 May 14-Nov 14 May 15+ Executive Education Project Planning and Scope Decisions Infrastructure & Interface Analysis Project Team Staffed and scheduled for training Delivery of System with Training Data (SWTD) Site Visit (3/25-3/27) Model System Variances Determined & Documented Project Team attends training at Epic and completes Certification Delivery of tailored version of Model System Validation Sessions (workflows) with Stoplight Evaluations (4/23-4/25) (5/14-5/16) Final Validation sessions Workflow User Labs Specialty Validation System Build completed Application, Interface and Integrated Testing Credential Training, Super-User Training, End-User Training Go-live readiness assessments / Dress Rehearsal Go-Live and cutover planning Post Live Visits by Epic Team Evaluation of Future Scope Tracking of Key Performance Indicators Prepare for Rollout Rollout Prepare for Upgrades Upgrade

12 Introduction Cathy McDonough-McGrath, MSN, RN Clinical documentation Nursing: M/S, ICU, Pediatrics Ancillary(secondary lead) Respiratory, Physical, Occupational, Speech Therapy, Social Work & Case Managers Bed Time HIM Reporting Renee Rolfe, MSN, RN, CNL ASAP Triage, Adult Acute, Pedi Acute, Trauma, Urgent Care, Observation Unit, Behavioral Health Unit, Project Assert Care Everywhere/ MyChart Participant in Clin Doc & CPOE 12

13 Workstream Structure Members Analysts and EHR team lead Clinical leads (nursing, providers, ancillary) Instructional designers EPIC AM / AC Content experts & clinical leads from other work streams as needed Work Weekly meetings Review workflows Weekly timeline check ins (Clinical Content Build Out timeline and week by week ) High Risk processes Complex work flows Highly integrated areas 13

14 Content Decisions & Validation Prep Work Review of current state and Epic foundation system Review of literature, evidenced based practice Created workflow and build recommendation documents Workflow and build demonstrations Decision Makers Nursing Clinical Educators and Subject Matter Experts Weekly meetings Content decisions and validation Reviewed emerge build Collected feed back from end users 14

15 Clinical Lead Meetings Nursing and Ancillary Weekly roll call Facilitated decisions that crossed workstreams Example: suicide assessment, Abuse screening, Scoring tools, Nursing notes (DARP format), Student nurses documentation & security Combined meetings (Nursing, Ancillary, Providers) Made decisions that impacted multiple disciplines Nurses & Providers partnered to investigate current state & EPIC foundation system Made recommendations to the group Example: Med Rec, Documentation of patient history, treatment teams, Shared documentation, Time out, Weight/Height display (Metric vs. English) 15

16 High Level Policy/Procedure and Workflow Decisions Prep Work Gap analysis of policy & procedures; current vs. future state Review of regulatory mandates Review of literature, evidenced based practice Created workflow and build recommendation documents Workflow and build demonstrations Decision Makers Clinical Leads Nursing leadership Physician and departmental leadership Administrative and Business owners Patient access, coders, revenue integrity, medical records, legal, compliance 16

17 Complex, Integrated Workflow Decisions I&O documentation LDA s (lines, drains, airways) Epidurals Phases of care MAR hold Patient movement (ADT) Code and Trauma Narrator Care plans Order sets Preference card clean up Medication barcode scanning 17

18 Clinical Lead Role in Configuration & Build Build Timeline Clinical content build out (CCBO) Week by Week Clinical Lead Role Project management to meet deadlines, maintain momentum and gain consensus At the elbow build First reviewers and test users Stork certified clinical leads participated in building flowsheets Participated in build nights 18

19 ASAP: Configuration and Build Monday Tuesday Wednesday Thursday / Friday Weekly ASAP workstream call 4 hour MD content review and validation 4 hour RN content review and validation At the elbow RN clinical lead and analyst build Build night (Thurs) Special Considerations Observation Unit Behavioral Health Unit Social Worker and Case Management Project Assert Residents Students 19

20 Clinical Lead Role in Testing Outcomes were twofold: identified build issues and served as a learning tool for end users Centralized testing location facilitated collaboration of all workstreams and ITS support Leads were responsible for initial and ongoing review and sign off of test scripts Participated in unit to full integration testing following scripts, with analyst support Rigor of the testing schedule proved difficult for consistent clinical lead and SME involvement during integrated testing 20

21 ASAP: Workstream Testing Ongoing ASAP analyst and Clinical Lead testing ASAP team shadow charting (similar to Optime) SME/ super user / RN educator shadow charting Pilot testing for major workflow changes 21

22 Training MD RN UC CNA Ancillary training 8 hours 16 hours 4 hours 4 hours 4-8 hours Special Considerations Research assistants Administrative, business owners, nursing leadership Coders/ revenue integrity staff Patient Access ED Greeters ED Social Workers and Case Managers View only access and training 22

23 Clinical Lead Role in Training Clinical leads instrumental in training the trainer about BMC workflows Partner with ID in lesson plan review, quick start guides, tip sheets approval and sign off Super users were crossed trained to other roles, 70+ hours / 2 weeks in the classroom Super users, Clinical Leads, Clinical Educators were used as teaching assistants in classroom RN educators & CTs offered additional simulation sessions for ED code and trauma narrator training 23

24 Operational Readiness Purpose 3 months pre- go live Major workflow changes Timeline updates Review of current state vs. future state Device and equipment check in Activation readiness and support check in Players Clinical Leads Business owners and administrative partners Nursing Leadership Nurse Educators Departmental Chairs and Administrative Attendings BMC application analysts Epic counterparts Instructional Designers 24

25 Clinical Dress Rehearsal Day 25

26 Cutover Preparation Round Table Technical Dress Rehearsal Two rehearsals Ran through entire timeline of cutover calling out associated owners, roles and responsibilities Documentation Cut Over Dress Rehearsal Two rehearsals Nursing and Pharmacy Clinical leads Super users Practiced process of data entry from legacy systems into emerge 26

27 Clinical Lead Role in Cutover Cut Over Activities Friday at 6am day before to 3am Nursing & Pharmacy: Ht/Wt/Allergies, enter & verify orders Highly organized, massive group of super users doing the inputting of information Ongoing reports run at intervals to catch new and changing orders Clinical Lead Role Clinical support in room Investigating difficult orders Discontinuing orders Troubleshoot issue 27

28 Clinical Lead Role in Activation Command Center Representatives from all areas of ITS and clinical leadership that impacted emerge Centralized design allowed for quick issue resolution 5 rooms: training, help desk, nerve center, 2 application rooms Clinical Lead Assignment Primary lead assigned to command center Other leads split between units & command center Duties Testing and approving emergent build items Resource to analyst, leadership, super users & end users Ad hoc meetings with end users to troubleshoot emergent issues Review and approval of emergent tip sheets Attended huddles to facilitate communication between command center and end users 28

29 Activation Support BMC Super Users Participated early on in build to act as content experts Valuable resource for clinical leads to understand workflows and documentation needs Acted as a classroom teaching assistant during end user training Transitioned to at the elbow support during go live Purple People Consulting group specialized in Epic implementation support On units at 3am for cut over Participated in daily huddles Ability to provide informed proposals for issue resolution Willing to take direction from nurse managers, educators & clinical leads on where to focus their efforts 29

30 Activation Tip and Tricks Decrease end user anxiety! Huddle! Huddle! Huddle! Communication is key! White board with At the Elbow Support assignments Designated times that Clinical Leads were in department for end user support Clear pathway of issue escalation 30

31 ASAP: At the Elbow Support 31

32 Evolution of the Post Go Live User Group Pre go live Operational Readiness Are we ready? Go live Daily Huddle What do we have to fix? Post go live Weekly User Group Where are we going? 32

33 Post Go Live Focus Optimization End user requests Suggestions from EPIC 2014 upgrade User group top ten prioritization Re-training MD and RN efficiency training Nursing competency day Biweekly emerge newsletter Tip sheet and quick start guide revisions Quality Improvement Initiatives Transitions of care and clinician hand off s Reporting and data collection Barcode scanning compliance Monitoring Meaningful Use and other critical compliance items Trauma documentation and trauma registry reporting 33

34 Lessons Learned Involve administrative and business owners early on Operational readiness workgroups should be formed earlier rather than later Involve clinicians in technical dress rehearsal Good note keeping and logging of decisions is vital to organization Clear documentation of assigned tasks and follow ups with due dates will reduce the swirl Application build cant be done in a vacuum! Need clinical buy in and approval from all workstreams 34

35 Lessons Learned Consistent involvement from SMEs and super users is the key to success at go live Small incremental changes should be applied pre- go live when possible Centralized Command Center key to smooth transition Think globally; consider the bigger hospital impact Positivity is contagious! Implementation is a marathon not a sprint! Be pre-pared for the post go live let down 35

36 Value of the Clinical Lead Role Bridge the gap between the end user and application analysts Clinical expertise was foundation for the build; reassured clinicians the system would be usable Cheerleaders! Walk a mile in my shoes! 36

37 Questions Thank you! 37